Tracking hospital infections

Ten years ago, Dr. Bob Chase would have laughed if someone had told him common infections could be eliminated in hospitals' intensive care units.

"I would have said that's ridiculous, not possible," he said. "As a physician, I was trained to believe bad things just happen."But Chase, vice president of quality at Norwegian American Hospital in Chicago, doesn't think that anymore. A growing body of research has convinced him that many infections can be prevented if proper procedures are rigorously followed -- evidence he's using to reduce higher-than-expected infection rates at his own institution.

The research is prompting a wave of improvements in hospital ICUs, and patients are starting to benefit: At many hospitals, the rates of some common infections have been cut in half or more, saving lives and money and preventing medical complications.

At the same time, states are releasing data about infections in a push to hold medical institutions accountable. Recently, Illinois published information -- the first of its kind -- showing which Illinois hospitals are succeeding in controlling certain hospital-acquired infections and which are not.

Of particular concern are infections involving central lines -- large catheters that doctors place in blood vessels to deliver medications and administer fluids. About 80,000 hospital patients are infected annually in the U.S. when pathogens invade the bloodstream through the catheters, and upwards of 30,000 die.

The germs can come from a patient's skin, doctors' ties, nurses' coats, the catheter itself and various other sources.

Many Illinois hospitals have had considerable success in reducing central line-associated bloodstream infections, known as CLABSIs. The Illinois Hospital Report Card and Consumer Guide to Health Care lists 44 as having none at all in their ICUs last year.

Others didn't do as well. Thorek Memorial Hospital in Chicago had the most CLABSIs of any intensive-care unit in the state last year, at 22. Its infection rate was 13 times higher than the U.S. average.

Other facilities with high rates include Roseland Community Hospital (almost nine times higher) and St. Bernard Hospital and Health Care Center (almost six times higher), both in Chicago.

Norwegian American also is among the poor performers, a fact Chase doesn't try to sugarcoat. "We take this very seriously," he said. The hospital reported 12 CLABSIs in its medical/surgical ICU.

Dr. John Jernigan, deputy chief of prevention at the federal Centers for Disease Control and Prevention, describes the national change in approach as "a real sea change" -- a sense of hope that major improvements in care are possible.

A turning point came when Dr. Peter Pronovost, a critical care specialist from Johns Hopkins Hospital, published research in 2006 in the New England Journal of Medicine demonstrating that more than 100 intensive care units in Michigan nearly eliminated CLABSIs by following a checklist of simple procedures.

When medical staff focused vigilantly on patient safety; worked closely together; washed their hands; used gloves, masks and gowns; draped patients with coverings, and rigorously cleaned sites where catheters were inserted, among other measures, infection rates in Michigan dropped to an average rate of 1.4 for every 1,000 catheter days, from 7.7 previously.

Although CLABSIs represent only a fraction of infections that patients get in hospitals, they're "the poster child for making a difference" in medical care, Pronovost said. "We know they are measurable and largely preventable."

Hospitals across the country took notice as the Institute for Healthcare Improvement, an influential Boston-based organization, adopted Pronovost's infection-fighting strategies in its 5 Million Lives Campaign. More than 180 Illinois hospitals participated in that voluntary 2006 to 2008 effort to prevent medical harm to patients.

Among the barriers were poorly designed systems and doctors convinced that fighting infections would take time and effort they didn't have, according to Fran Griffin, an institute director.

One facility that took Pronovost's strategies to heart was Central DuPage Hospital in Winfield, which last year had one infection in its two medical/surgical ICUs, down from 19 in 2008.

After reviewing its performance, Central DuPage discovered that many central line infections occurred days after the catheter was inserted. When hospital staff instituted a dozen steps designed to maintain the sterility of the line, infections plummeted, according to Dr. David Cooke, the hospital's vice president of quality and safety.

Another was Adventist Bolingbrook Hospital, which has not had a single central line infection in its ICU since the hospital opened in January 2008. From the start, the medical center has followed Pronovost's checklist.

"We have a systematic, standardized evidence-based approach to central lines, and the staff and physicians have become the best supporters of the program," said Dr. Richard Carroll, regional vice president and chief medical officer for Adventist Midwest Health.

At Loyola University Medical Center in Maywood, staff began paying more attention to how central lines were inserted, their daily care, and bathing patients with chlorhexidine, a chemical antiseptic. Central lines placed in the emergency room are now routinely removed and replaced in the ICU under more sterile conditions.

"When people started doing this, the rates fell," said Dr. Jorge Parada, Loyola's director of infection control. "And then it was like, 'Duh, why were we not doing this all along?' "

Northwestern Memorial Hospital in Chicago, along with the Northwestern Feinberg School of Medicine, carried out research showing that infections also can be cut by teaching doctors-in-training the best way to insert a central line on a simulator using a headless, armless dummy. The physicians, known as residents, were taught to use "a central line bundle" checklist as well.

Such improvements save not only lives but money. Patients who survive central line infections spend an extra week in the hospital, on average, and incur up to $30,000 in additional medical expenses, according to the Institute for Healthcare Improvement.

Fifty-two Illinois hospitals are now participating in a collaborative designed to eliminate CLABSIs in ICUs led by Pronovost, the Illinois Hospital Association and a unit of the American Hospital Association. More are expected to join this summer.

Yet some hospitals are lagging, with unusually high CLABSI rates that raise questions about the quality of care.

In an interview, Thorek Memorial president Frank Solare said "patient safety, infection control, quality performance is our No. 1 priority." Asked about the high number of infections, officials blamed a former employee for possibly "over-reporting" infections and not keeping management informed.

The North Side hospital is reviewing all 22 CLABSI cases reported to the state and has implemented several procedures to lower the number of infections. It began using a Pronovost-style central line checklist in March, has ordered new dressings to keep insertion sites clean, and has updated equipment included in its central line "kit," a package of items needed to put in a line.

So far this year, only one ICU patient at Thorek has contracted a central line infection, officials said.

At Roseland Community Hospital, infection control coordinator Rose Chavis said the South Side hospital had misclassified six infections because it was using outdated criteria. Roseland also miscounted how many days patients had central lines inserted in its medical/surgical ICU, Chavis said.

To drive down infection rates, Roseland is using new equipment, emphasizing hand hygiene and monitoring central lines daily. "We are following every single item" on the Pronovost checklist, Chavis said.

Reducing infections also requires a change in culture at medical institutions, Pronovost writes in his new book, "Safe Patients, Smart Hospitals." For example, nurses must be supported if they report a physician who skips checklist steps.

"We've had a checklist for a couple of years and it didn't make a difference," said Chase of Norwegian American. "It's insisting on holding staff accountable and a culture of excellence -- that's the really hard part."